Prediction and prevention of patient falls

Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program

Background

Patient falls in hospitals are common and may lead to negative outcomes such as injuries, prolonged hospitalization and legal liability. Consequently, various hospital falls prevention programs have been implemented in the last decades. However, most of the programs had no sustained effects on falls reduction over extended periods of time.

Methods

This study used a serial survey design to examine in-patient fall rates and consequent injuries before and after the implementation of an interdisciplinary falls prevention program (IFP) in a 300-bed urban public hospital. The population under study included adult patients, hospitalized in the departments of internal medicine, geriatrics, and surgery. Administrative patient data and fall incident report data from 1999 to 2003 were examined and summarized using frequencies, proportions, means and standard deviations and were analyzed accordingly.

Results

A total of 34,972 hospitalized patients (mean age: 67.3, SD ± 19.3 years; female 53.6%, mean length of stay: 11.9 ± 13.2 days, mean nursing care time per day: 3.5 ± 1.4 hours) were observed during the study period. Overall, a total of 3,842 falls affected 2,512 (7.2%) of the hospitalized patients. From these falls, 2,552 (66.4%) were without injuries, while 1,142 (29.7%) falls resulted in minor injuries, and 148 (3.9%) falls resulted in major injuries. The overall fall rate in the hospitals' patient population was 8.9 falls per 1,000 patient days. The fall rates fluctuated slightly from 9.1 falls in 1999 to 8.6 falls in 2003. After the implementation of the IFP, in 2001 a slight decrease to 7.8 falls per 1,000 patient days was observed (p = 0.086). The annual proportion of minor and major injuries did not decrease after the implementation of the IFP. From 1999 to 2003, patient characteristics changed in terms of slight increases (female gender, age, consumed nursing care time) or decreases (length of hospital stay), as well as the prevalence of fall risk factors increased up to 46.8% in those patients who fell.

Conclusion

Following the implementation of an interdisciplinary falls prevention program, neither the frequencies of falls nor consequent injuries decreased substantially. Future studies need to incorporate strategies to maximize and evaluate ongoing adherence to interventions in hospital falls prevention programs.

A failed fall prevention study in an acute care setting: lessons from the swamp

Designing and implementing fall intervention studies in acute care settings presents researchers with a number of challenges. To date, there are no fall prevention interventions that have unequivocal empirical support in these settings. Based on the best available evidence a multistrategy fall prevention program was implemented using a pretest-post-test design over a 12-month period. The results indicated no reduction in the fall rate. Contrary to the expected result, the fall rate increased post the implementation of the multistrategy fall prevention program. To assist other researchers understand the contextual and methodological barriers to conducting fall prevention research in acute care settings, this paper discusses the difficulties experienced in this study.

Do hospital fall prevention programs work? A systematic review

OBJECTIVES

To analyze published hospital fall prevention programs to determine whether there is any effect on fall rates. To review the methodological quality of those programs and the range of interventions used. To provide directions for further research.

DESIGN

Systematic review of published hospital fall prevention programs. Meta-analysis.

METHODS

Keyword searches of Medline, CINAHL, monographs, and secondary references. All papers were included that described fall rates before and during intervention. Risk ratios and 95% Confidence Intervals (95% CI) were estimated and random effects meta-analysis employed. Begg's test was applied to detect possible publication bias. Separate meta-analysis regressions were performed to determine whether individual components of multifaceted interventions were effective.

RESULTS

A total of 21 papers met the criteria (18 from North America), although only 10 contained sufficient data to allow calculation of confidence intervals. A rate ratio of <1 indicates a reduction in the fall rate, resulting from an intervention. Three were randomized controlled trials (pooled rate ratio 1.0 (CI 0.60, 1.68)), seven prospective studies with historical control (0.76 (CI 0.65, 0.88)). Pooled effect rate ratio from these 10 studies was 0.79 (CI 0.69, 0.89). The remaining 11 studies were prospective studies with historical control describing fall rates only. Individual components of interventions showed no significant benefit.

DISCUSSION

The pooled effect of about 25% reduction in the fall rate may be a result of intervention but may also be biased by studies that used historical controls not allowing for historical trends in the fall rate before and during the intervention. The randomized controlled trials apparent lack of effect might be due to a change in practice when patients and controls were in the same unit at the same time during a study. Studies did not analyze compliance with the intervention or opportunity costs resulting from the intervention. Research and clinical programs in hospital fall prevention should pay more attention to study design and the nature of interventions.

Initiation and evaluation of a research-based fall prevention program

This study evaluated the effectiveness of research-based interventions in preventing falls. The interventions were based on research studies, experts' opinions, and a pilot study. Thirteen units (72%) had reduced fall rates. The fall rate two years before (O = 7.07; SD = 1.7) and two years after (O = 6.33; SD = 1.731) the intervention was significantly different at p < 0.003. Sixteen patients who fell were at risk (fall assessment score = 17.4 +/- 5.3) and had a history of falls. The most common site for falls was at the bedside. Most falls occurred during walking, climbing over the siderails, and accidentally rolling out of bed. Thus, a research-based fall prevention is effective in reducing falls.

Review of the literature on falls among the elderly

PURPOSE

To review and summarize the literature from nursing, medical, and ancillary fields on falls among the elderly. Major injuries from falls are associated with mortality, especially among the elderly. Researchers indicate that, in many cases, falls can be prevented. A summary of the available literature provides information which can be used to plan interventions.

ORGANIZING FRAMEWORK

Over 100 publications, 1979-1996 related to falls by elderly were reviewed. Descriptive terms used for searching MEDLINE were falls, elderly, and accidents. Literature from several disciplines was reviewed.

FINDINGS

Fall risk can be predetermined and nursing actions can be taken to reduce the occurrence and severity of falls.

CONCLUSIONS

To reduce the deleterious effects of falls in the elderly, knowledge-based practice is essential.

Collaboration: a framework for clinical quality improvement

Healthcare organizations are being challenged to find ways to leverage improvement efforts. Collaboration offers an avenue for working together toward a common goal. Healthcare leaders can initiate collaborative projects to analyze common clinical problems and to share best practices. This article describes how a Catholic healthcare system successfully initiated a systemwide collaborative clinical quality improvement project to deal with patient falls.

Clinical nursing judgment related to reducing the incidence of falls by elderly patients

The incidence of falls among elderly patients has been and continues to be a major challenge for nurses. Falls add physical injury and mental stress to patients' existing health problems, are a deterrent to rehabilitation, and increase healthcare costs. This study describes the variables that nurses identify as influencing their clinical decision making and the nursing behaviors associated with preventing patient falls. The study was grounded in the theory that discretionary nursing behaviors are related to nursing expertise, and the study was guided by the assumption that such behaviors are proactive and anticipatory. An analysis of interviews of registered nurses (n = 14) working on a geriatric rehabilitation unit in a medical center in Ohio focused on the zones of association and the contextual meanings of language used by the nurses when discussing patient falls. Four themes emerged: the reasons for patient falls, identifying patients who are likely to fall, preventing falls, and nurses' feelings when patients fall.

Near falls incidence. A study of older adults in the community

1. Although falls in older adults have been studied in a variety of settings, near falls (or almost falling) have received little or no attention--and therefore their clinical relevance is unknown. 2. Older adults were able to discriminate between near fall and actual fall events without difficulty. 3. Thirty-five percent of the older adults who participated in this study experienced near falls in the 3-weeks of data collection. Therefore, near falls are common events in the lives of many older adults.

Geriatric falls: prevention strategies for the staff

1. Multiple falls and injuries are more prevalent among elderly over the age of 75 and are the second leading cause of accidental death in the elderly. The risk for falling is noted to be significantly greater in the hospitalized elderly. 2. Review of retrospective quality improvement chart audits revealed that peak fall times were associated with the patient's need for toileting, rest, and obtaining nutrition and hydration. 3. The MetroHealth Falls Prevention Program is based on simple proactive measures to prevent falls in the elderly. 4. An effective falls prevention program has several implications for gerontological nursing practice, including less restraint use, increased patient autonomy, and decreased loss of self-esteem. There is also a sense of increased nursing control over patient safety and time management, as well as implications for further nursing research.

Falls in the nursing home: preventable or inevitable?

1. Falls in the elderly are frequent occurrences and are usually a result of the complex interaction of environmental, physiological, and pathological variables. Fall-related injuries happen much less frequently. 2. Physical restraints have not been found effective in preventing falls and may be associated with increased risk of fall-related injury. 3. Because of the complex nature of falls in the elderly, fall prevention programs must emphasize the critical assessment of each resident's risks for falling with targeted interventions.